Entry - Tennis Seniors Australia

2013MURGON & DISTRICT TENNIS ASSN INC.Entry FormSurname ........................................................... First Name............................................. .Address ............................................................................................................................... ........................................................................... State ....................... Postcode .............. .Phone No. (Home) ............................................ Work ....................... Fax ....................... .Email. ................................................................ Mobile ................................................... .Contact phone no. during Tournament ........... .. ................................................................. .Date of birth…………………Male or Female (circle) ITF World Ranking…..… (S)………(D)Tennis Seniors Aust. Ranking – (S)……(D)……@ ……/……/…….Player Rating No.N……I am a member of………………………………… Tennis Club/Assoc..2013 Tennis Seniors Rego.No………….2013 MYTENNIS IDNo. ....................................... .EventNo.Name of Event Partners Name FeesSat am $Sat pm $Sun am $Sun pm $A or BGRADEPLEASE CIRCLEONE.2013 Tennis Seniors Queensland Membership Fee - $20.00 (Refer Condition 3)Please nominate which Seniors Club you wish your membership to be credited to:____________SPECIAL CONDITION: Temporary Seniors m/ship for this tournament only $10.00(Refer to Condition 3 – for interstate/overseas players only)$$Total Amount Enclosed $Entry Fees: Singles $16.00 Doubles $14.00 per player_______________________________________________________________________Office Use: Amount Rec’d $ Date Rec’d Receipt No.____________________________________________________________________________________________________________Entries close 19 th AUGUST 2013Cheques payable to:Send entries to:Murgon Tennis Assn Inc.Dianne ZelinskiP.O. Box 208Murgon. 4605. Qld.Player Agreement & Release must be signed by the entrant only or their entry will not be accepted.See on reverse side.

2013MURGON & DISTRICT TENNIS ASSN24 th & 25 th AUGUST 2013.Player Agreement and ReleaseIn consideration of your agreement to allow me to participate in the Murgon Seniors Tournament atMurgon in 2013 (“The Event”), I hereby agree as a condition of participation in the Event, to waive,for myself, my executors, administrators, heirs, and personal representatives, all claims of anykind, nature and descriptions including past, present or future, including any claims in respect ofinjuries sustained in travelling to, from, or participating in the Event against Murgon Tennis AssnInc, Tennis Seniors Queensland Inc., Tennis Seniors Australia, Tennis Queensland, TennisAustralia or participating Tennis Clubs.I confirm I have read the above Terms, Rules and Conditions and agree to abide and be bound bythem together with the conditions of entry provided within this form.Surname of Player ............................................ First Name .................. Initials ..............Signature .............................................................................. Date ......... / ......... / .................Players History FormFor seeding purposes, please list below details of your relevant record of play including wins andlosses for the past 12 months. Kindly include the name of your opponent in each case.Date Venue Result(including name of opponent)Other